The HIV/AIDS epidemic, first identified in 1981, remains among the greatest threats to global health, with an epicenter in the acutely affected countries of east and southern Africa (Independent Task Force Report No. 56, 2006; UNAIDS and WHO, 2009). Life-saving antiretroviral therapy (ART) was, until 2000, not accessible to those most in need because they were poor and lived in developing countries. With the turn of the 21st century, global attitudes on this morally intolerable situation began to shift, and the International AIDS Conference in Durban in July 2000 marked a turning point with a powerful call to the international community to take responsibility for mounting an urgent response.

The United States responded and, with the launch of the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) in 2003, established itself as a global leader in the fight against HIV/AIDS. Through PEPFAR and support for the Global Fund to Fight AIDS, Tuberculosis and Malaria, the United States helped galvanize an extraordinary global response to a single disease and mobilize donor and private-sector resources on an unprecedented scale to respond to the costly but critical task of addressing the HIV/AIDS crisis. Perhaps most important, this response demonstrated, in the face of considerable skepticism at the time, that dramatically expanding access to HIV/AIDS treatment was possible even in the world’s most resource-constrained settings (IOM, 2007). The U.S. campaign against HIV/AIDS has had a historic impact and is considered among the most significant and enduring achievements of the George W. Bush administration (Stolberg, 2008).

Yet despite its substantial immediate impact, this emergency response has failed to halt or reverse the HIV/AIDS epidemic in Africa. Indeed, as outlined in the previous chapter and Appendix A, the burden of HIV/AIDS in Africa will continue to grow. As a result of continued high HIV incidence rates, the need for lifelong HIV/AIDS treatment has grown more rapidly than the ability to initiate new patients on ART. This growing burden will place ever higher demands on health care services, including an increasing number of ambulatory and hospitalized patients requiring HIV/AIDS care, an increasing number of patients requiring ART, a substantial need for additional health care workers, and a continued rise in financial and other resource requirements.

In the context of this growing burden, the United States and the global community will face significant challenges in sustaining and expanding commitments to combating HIV/AIDS in Africa. In the United States, the effects of a historic global financial crisis and a domestic deficit approaching $2 trillion will likely drive greater congressional scrutiny of spending on foreign assistance (Garrett, 2010). Moreover, the success of the U.S. HIV/AIDS effort has, ironically, increased attention to other African health challenges, which may drive competition in resource allocation among disease and health priorities. Beyond health, U.S. interests in Africa have expanded dramatically in the last decade, resulting in growing recognition of new challenges that confront development in such areas as food security, climate change, and unemployment and creating

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